Adequately iodized salt can protect children from brain damage, but only three quarters of the world’s households are using it

Iodine deficiency can lead to a variety of health and developmental consequences known as iodine deficiency disorders (IDDs). Iodine deficiency is especially damaging during the early stages of pregnancy and in early childhood. In their most severe forms, IDDs can lead to cretinism, stillbirth and miscarriage; even mild deficiency can cause a significant loss of learning ability. In 2013, more than 35 million newborns were unprotected from the lifelong consequences of brain damage associated with iodine deficiency.

For the last 30 years, universal salt iodization has been the most widely used strategy to control and eliminate IDDs. The target aims for consumption of adequately iodized salt in more than 90 per cent of households. However, this goal is a long way from being met.

UNICEF estimates that, globally, 75 per cent of all households consumed adequately iodized salt in 2013. East Asia and the Pacific is closest to reaching the target of more than 90 per cent of households. In contrast, only about half of the households in Least Developed Countries met the target, pointing to the need for enhanced efforts among those most vulnerable.

Globally, only three out of four households are consuming adequately iodized salt, putting far too many children at risk

Sub-Saharan Africa has the highest number of unprotected newborns, with more than 14 million infants at risk of IDDs in 2013 followed by South Asia with 11 million. East Asia and the Pacific is the top-performing region despite the high birth rate, although progress is largely attributed to coverage increases in China.

Globally, more than 35 million newborns were at risk of iodine deficiency disorders in 2013

Number of newborns unprotected and protected from iodine deficiency disorders (IDDs) as assessed through household consumption of adequately iodized salt (millions), 2013

DISPARITIES IN COVERAGE

No predictable patterns of disparity are found for household consumption of iodized salt in relation to relative wealth. When recent data for 44 countries were analysed, over one third of countries showed that the richest and poorest 20 per cent of the population were roughly equal in terms of their consumption of iodized salt (the green circles in the figure below). In another third of countries, the richest quintile was at least twice as likely as the poorest quintile to consume adequately iodized salt (red circles). Ghana showed the widest disparities: In that country, the wealthiest quintile was more than nine times more likely to consume adequately iodized salt than the poorest quintile. In Mozambique, the rich have a fourfold advantage. Five countries showed a difference of more than 40 percentage points between the richest and poorest quintiles: Algeria, Ghana, Madagascar, Senegal and the United Republic of Tanzania.

The data also show that countries with higher overall coverage (circles in the top right quadrant) tend to have more equitable distribution of coverage. Some exceptions are Egypt, Lesotho and Nepal, which have high overall coverage but show stark disparities based on wealth. This calls attention to the need to identify and address barriers to the equitable use of adequately iodized salt in affected countries.

Equity between the richest and poorest quintiles in consumption of iodized salt is evident in about a third of countries

Percentage of households consuming adequately iodized salt among the richest and poorest quintiles, in 43 countries with available data, 2006–2011

Notes: Based on 43 countries with available disparity data. Each circle represents data from one country. The size of a circle is proportional to the size of the country's population. The horizontal axis represents the percentage of the poorest quintile consuming adequately iodized salt, while the vertical axis represents the percentage of the richest quintile. Circles along the green line represent countries in which the likelihood of consuming adequately iodized salt is similar among the richest and the poorest quintiles. Circles above or below the green line suggest disparity. The closeness of circles to the upper-left corner indicates greater advantage for the richest quintile in that country (greater disadvantage for the poorest quintile).

Equity between the richest and poorest quintiles in consumption of iodized salt is evident in about a third of countries

Percentage of households consuming adequately iodized salt among the richest and poorest quintiles, in 43 countries with available data, 2006–2011

Notes: Based on 43 countries with available disparity data. Each circle represents data from one country. The size of a circle is proportional to the size of the country's population. The horizontal axis represents the percentage of the poorest quintile consuming adequately iodized salt, while the vertical axis represents the percentage of the richest quintile. Circles along the green line represent countries in which the likelihood of consuming adequately iodized salt is similar among the richest and the poorest quintiles. Circles above or below the green line suggest disparity. The closeness of circles to the upper-left corner indicates greater advantage for the richest quintile in that country (greater disadvantage for the poorest quintile).

CHANGES OVER TIME

Comparable trend data are not available for this indicator, which limits reporting on global or regional changes to the proportion of households consuming adequately iodized salt. However, comparable data for a few countries show that the situation can change rapidly – either positively or negatively. Paraguay has shown incremental increases over the last 15 years, and has maintained its target level of consumption since 2006. This is an important achievement, but one that can only be demonstrated if household consumption of iodized salt is measured in a comparable manner periodically (every three to five years). Data from Lebanon and Viet Nam show that success can erode quickly, and that sustained efforts are required to ensure that vulnerable populations remain protected. Certain countries have been officially recognized for achieving the 90 per cent coverage target at one point in time. However, maintenance of that coverage level cannot be assumed if current status (based on data within the last five years) is unknown due to a lack of continuous data collection and reporting.

Sustained efforts and continuous reporting are necessary since changes in household consumption of iodized salt can shift rapidly

MONITORING ELIMINATION OF IODINE DEFICIENCY DISORDERS

A set of guidelines for monitoring IDD control programmes with both process and impact indicators are described in the World Health Organization (WHO) manual, Assessment of Iodine Deficiency Disorders and Monitoring Their Elimination. With regard to process, it is important to monitor salt iodine content at the levels of production/importation, retail/wholesale sales, and in the household (consideration should also be given to assessing the use of iodized salt in the food industry, where relevant). To monitor impact, median urinary iodine is the main indicator for assessing a population’s iodine status, with total goitre prevalence providing additional useful information. WHO maintains a database on programme impact with indicators related to urinary iodine and goitre prevalence.[1] UNICEF maintains a database on household consumption of iodized salt. Currently, no agency is responsible for reporting on other process-related indicators regarding production, importation or sales. Ideally, the entire set of process indicators should be combined with impact data to best guide programmes and policies in individual countries.

THE INDICATOR

The indicator presented on this page, ‘Proportion of households consuming adequately iodized salt’, provides part of the picture with regard to monitoring IDD elimination efforts.

Indicator name

Definition

Numerator

Denominator

Proportion of households consuming adequately iodized salt

Number of households with salt iodine content ≥ 15 parts per million (ppm)

Number of households surveyed with salt tested for iodine content and households without salt

The indicator definition for adequately iodized salt specifies a minimum of 15 parts per million (ppm) of iodine in salt. The amount of iodine in salt samples is important to assess: To be fully effective in correcting iodine deficiency, salt with iodine must not only reach the entire affected population, it also needs to have enough (yet not too much) iodine. While some countries may have different targets, the WHO recommendation is to have 15 to 40 ppm of iodine for salt at the household level, thus the definition used is ≥ 15 ppm.

The assessment of iodine content has generally been accomplished through the use of rapid test kits. While the test kit cannot provide data that are as precise and accurate as titration, it remains the test method associated with most data points in UNICEF’s global database. Based on recommendations from WHO to only use rapid test kits to indicate the presence of iodine, and to use another method – titration – to quantify and report on salt with a particular amount of iodine, a number of countries have stopped reporting on the cut-off of ≥15 ppm and only report on salt with any iodine (>0 ppm) in many recent surveys.

DATA COLLECTION AND REPORTING

Data for household consumption of adequately iodized salt are collected mainly though nationally representative household surveys, such as MICS and DHS. A more limited number of national estimates in the UNICEF global database come from primary school-based surveys or surveillance systems in countries where the primary school net enrolment rate exceeds 90 per cent.

LIMITATIONS

There are a variety of limitations associated with reporting on progress in household consumption of adequately iodized salt, many of them linked to advancements in methodologies and programme maturation. Great strides have been made in enhancing programme monitoring, leading to increased availability and improved quality of data over the past decade. At the same time, they render older data points non-comparable to newer ones, thereby limiting the ability to undertake trend analyses. Some key issues are highlighted below:

Shift from monitoring production to household consumption

Questions about household consumption of iodized salt were only added to major household surveys starting in the mid-1990s. And even then, not all countries had estimates based on household data. In the early to mid-1990s, many national estimates presented in UNICEF’s annual report The State of the World’s Children were based on extrapolations from iodized salt production figures. Since these estimates are not comparable to the current household consumption-based data, they cannot be used for trend analysis.

Testing for iodine in household salt samples

Self-reporting: Although the move from production to household consumption-based estimates was a positive one, it still introduced some bias since early estimates were often based on self-reporting. Even some early DHS did not test household salt for the presence of iodine, relying on self-reporting by the respondent or a cross-check against the label/brand name of the salt by the survey interviewer. These self-reported estimates are not comparable to the current household consumption-based data, and cannot therefore be used for trend analyses.

Rapid test kits: These kits allow for semi-quantification of iodine content and were introduced into many surveys in the mid- to late 1990s as a means of cross-checking a sample of salt within the household during the survey. This helped in decreasing the bias of estimates based on self-reporting from household survey data and represents one of the first examples of direct testing in household surveys. Currently, nearly all MICS and DHS as well as most other national household surveys/monitoring mechanisms include a salt-testing component using rapid test kits for iodine.

Titration: The most recent WHO recommendation is to use titration to quantify iodine content in salt samples gathered through household surveys. These recommendations also call for use of rapid test kits to indicate presence of iodine only, not adequate iodine (>15 ppm). Since the use of titration has been slow to catch on, and with many countries only reporting on salt with any iodine based on rapid test kits, the ability to construct trends has been further compromised.

The maximum threshold for iodine in salt is not considered: In attempting to measure ‘adequate’ iodine in salt, the most frequent test method (rapid test kits) look only at the minimum – and not maximum – amount. However, excess iodine can also lead to health problems, and the absence of an acceptable upper range in most data points available limits the interpretability of the data.

Country-specific iodine targets: Some countries have alternate targets for iodine in salt (for example, neither ≥ 15 ppm nor 15–40 ppm) based on their specific salt consumption patterns, the availability of iodine through sources other than table salt, etc. This further complicates the ability to compare data over time and across countries.